Utilization Management Nurse

Skills: Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4. Experience in utilization management and/or medical review preferred. Communication: Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.

Duties:
Utilization Management:

• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards. Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Communication:

• Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.

Compliance:

• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.

Workflow:

• Proactively and efficiently work incoming and outbound calls and/or queues from multiple sources within mandated requirements.

Knowledge:

• Remain current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
• Other duties as assigned.

Skills:

• Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding 4.
• Experience in utilization management and/or medical review preferred.

Specialized Knowledge & Skills:

• Ability to prioritize and make sound nursing judgments through critical thinking
• Excellent verbal and written communication skills
• Ability to build collaborative relationships
• Attention to details
• Ability to interpret complex documentation